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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425334
Report Date: 03/17/2023
Date Signed: 03/17/2023 01:55:58 PM

Document Has Been Signed on 03/17/2023 01:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:COMMUNITY CROSSINGS INC.FACILITY NUMBER:
336425334
ADMINISTRATOR:ANDRADE, AUDREYFACILITY TYPE:
775
ADDRESS:27363 JEFFERSON AVENUE STE. JTELEPHONE:
(951) 296-2158
CITY:TEMECULASTATE: CAZIP CODE:
92590
CAPACITY: 60CENSUS: 42DATE:
03/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Terry Woodrow, Program DirectorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Janira Arreola and Jacqueline Shaw Ross conducted an unannounced annual required visit on 3/17/2023 at 09:30 a.m. LPA was granted entry and met with program Director, Terry Woodrow, who was informed of the purpose of the visit.

The facility is a one story facility with (4) activity room and (5) bathrooms for clients between the ages of 18 and above. LPA conducted a tour of the interior and exterior of the facility and observed the following:

Infection Control: The LPA observed the hand washing stations in the facility had a hand washing sign with proper steps on hand washing. LPA also observed gloves in client restrooms and changing areas, and cleaning supplies to do regular cleaning of the facility. The facility is currently screening clients when coming to the program. The facility was not able to present the LPAs with a copy of the infection control plan. LPA will issue a technical note for this to be available at the facility.



Physical Plant: LPA observed activity materials in activity rooms. Physical plant, floors, windows, and doors were observed to be clean and in good repair. Fixtures and furniture were in good repair and were present. There is an adequate number of activity rooms for the capacity of the facility. The outdoor area was observed to have a shaded area for clients and was free of hazards. Chemicals were observed in a locked maintenance closet. LPA will issue technical advisory note for staff to place blender in a locked cabinet to make it inaccessible to clients. LPAs observed (2) buckets on the floor of the facility file room, and asked the staff about leak in the ceiling. LPA was informed that communication with building management on repairs that were actively being conducted. This room is not accessible to consumers. The hot water temperature was recorded at 119F in one of the client restrooms.

Food Service: LPA observed kitchen used to store client lunches. The LPA observed Goldfish snacks that had a sell by date of 1/15/2023. LPA will document a technical advisory note for staff to discard these as there is no expiration date to verify freshness. LPA observed the kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: COMMUNITY CROSSINGS INC.
FACILITY NUMBER: 336425334
VISIT DATE: 03/17/2023
NARRATIVE
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Care & Supervision/Administration: Adequate staff are present for the supervision of clients. Emergency exiting plans, telephone numbers and personal rights were found posted in the facility. The listed administrator was contacted over the phone, and informed the LPAs that they did not have the required continuing education hours. A type B deficiency is being issued and plan of correction was documented. During staff interviews, it was found that staff had difficulty answering question #5 on resident personal rights. LPA discussed training practices with the Program Director and advised the director to retrain staff on personal rights. This will be documented on a technical advisory note.

Record Review and Resident/Staff Files: LPA noted on the facility staff roster that one (1) staff, Staff #1 S1, was not associated to the facility roster. The facility will receive a type A deficiency for this with attached civil penalty of $500. Plan of Correction was documented for this. The staff was able to provide the LPA with the correction at the time of the visit. All other staff have criminal clearance and updated training along with CPR/First Aid Certification. Staff files were also found to be missing the required health screening. LPA will document a Type B deficiency for this as health screenings were not made available for review during the time of the visit. Plan of correction as documented for this. The resident files were also found to be complete, with the exception of (1) client file that had an outdate IPP plan. LPA reviewed the client monthly goals, and received email proof of why the IPP was not provided to the facility.

Health Related Services/ Incidental Medical Services: All resident medication was locked in a medication room.

Disaster preparedness: LPA reviewed the facility emergency and disaster plan. LPA reviewed documentation showing the facility fire alarms had been inspected and fire drill was conducted on 3/14/2023. LPA observed that all rooms had a facility sketch along with LIC610D sheet with emergency procedures. LPA requested a written disaster plan, which the staff was unable to locate during the time of the visit. LPA will document technical advisory note for LIC610D sheet to be updated to the new LIC610D. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report along with LIC 809-D pages and appeal right were provided to Program Director Terry Woodrow.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 12
Document Has Been Signed on 03/17/2023 01:55 PM - It Cannot Be Edited


Created By: Janira Arreola On 03/17/2023 at 01:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COMMUNITY CROSSINGS INC.
FACILITY NUMBER: 336425334

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82018(e)(2)
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health
and Safety Code Section 1522 shall do the following:
(2) Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f); or
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview, and record review, the licensee did not comply with the section cited above with S1 who was not associated to the facility. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2023
Plan of Correction
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The facility staff agreed to send the LPA the LIC9182 transfer form for the staff along with a clear current copy of the ID. This shall be sent by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 03/17/2023 01:55 PM - It Cannot Be Edited


Created By: Janira Arreola On 03/17/2023 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COMMUNITY CROSSINGS INC.
FACILITY NUMBER: 336425334

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82064(d)

(d) The administrator shall receive and document a minimum of 30 clock hours of continuing education every 24 months of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with facility listed administrator stating over the phone to the LPA that they did not have the 30 hours of the continuing education requirments. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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The staff agreed to send in a signed statement acknowledging that they have read and understood the section cited above. This shall be sent by the POC due date.
Type B
Section Cited
CCR
82066(c)
(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records
may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above with (2) sdtaff health screenings that were not availabel at the time of the visit for the LAPs to review. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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The staff agreed to send these health screenings to the LPA by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023


LIC809 (FAS) - (06/04)
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